decisionhealth Newsletters, Part B News - 2013 Issue 10 (October)
5 steps to stop private payers from passing sequestration cuts to you
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Article Overview
This article covers CMS guidance related to sequestration cuts and the impact on provider reimbursement under private payer and Medicare Advantage arrangements. It is aimed at physicians, medical practice managers, billing staff, and healthcare attorneys who need to understand contract language, payer payment practices, and dispute options when reimbursement reductions are applied. The article presents general guidance on reviewing contracts, monitoring payments, challenging improper reductions, and watching for contract revisions.
Why This Topic Matters
It helps providers identify when payer reimbursement reductions may be inconsistent with contract terms or CMS guidance, which can affect revenue and contract negotiations.
Article Sections
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Providers must protect themselves
This section discusses CMS guidance, payer reimbursement practices, and the importance of contract language in determining whether payment reductions may be applied.
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How to stop inappropriate claims reductions
This section outlines broad steps for reviewing contracts, monitoring reimbursements, raising disputes, and tracking contract changes related to payer payment reductions.
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Note
This section addresses a limitation affecting certain Medicare Advantage payment situations and explains that the guidance may not apply uniformly across all provider arrangements.
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Resource
This section points to a CMS guidance document referenced by the article.
What You Will Learn
- How CMS guidance relates to sequestration-related payer payment reductions
- What contract language may affect whether a payer can reduce reimbursement
- What general steps providers can take when they suspect an improper reduction
- How contract updates and payer disputes can affect reimbursement issues
- Which broad payer arrangements may be affected differently by the guidance
Who Should Read This
- Physicians
- Medical practice managers
- Billing and reimbursement staff
- Healthcare attorneys
- Revenue cycle professionals
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